An Arkansas midwife is facing disciplinary action for respecting her homebirth client’s wish not to have vaginal exams during pregnancy.
Mary Alexander works in the US state of Arkansas as a lay midwife (an uncertified or unlicensed midwife who has informal education, rather than formal education).
She is under fire for not abandoning her pregnant client who made an informed decision to refuse vaginal exams that were medically unnecessary.
Vaginal Exams And The Right To Say No
In October of 2017, the Arkansas health department made it mandatory for women to have vaginal exams as part of their pregnancy health assessments. The exam is to be performed by a health department clinician, a certified nurse-midwife, or a doctor – even if none of these care providers is to be involved in the actual birth.
The exams are meant to determine whether a pregnant woman has any medical conditions that would make birth at home an unsafe option for her. The checks include: whether her pelvis is large enough; whether there are genetic conditions that preclude vaginal birth; and whether there are infections that could be passed on to the baby.
The health regulations prevent a lay midwife from attending a birth unless her client has had two vaginal assessments – one at the beginning of pregnancy and one at 36 weeks.
Ms Alexander, who is chairman of the state’s Midwifery Advisory Board, appeared before a Department of Health committee to argue her case, and to explain why she shouldn’t be forced to coerce clients into having a vaginal exam or drop them if they don’t agree.
In a statement, William Greenfield, medical director for the Health Department’s family health services, said the regulation had been developed by a panel of department nurse practitioners, to ensure standard practice across different health units in the state.
Are Vaginal Exams Really Necessary?
Although this particular situation is limited to one state in the US, it is becoming a depressingly familiar story. Women are being told what they can and can’t do with their own bodies, during pregnancy and while giving birth.
Vaginal exams, whether during pregnancy or during labour, are interventions and not the simple, normal fact finding missions they are often presented to be.
Today’s maternity care is considered medically advanced, compared with the old ways in which women were cared for. Even so, there is a distinct lack of holistic understanding and trust of women’s bodies and birth, which plays a very important role in the way women are cared for.
For centuries, pregnant women have probably explored their own bodies, discovering how their growing uterus influences the changes to the vagina and cervix. It’s not impossible to imagine a midwife or experienced woman checking to see whether a labouring woman’s cervix was dilating or whether baby was in the right position for birth.
However, as the medical profession began to assume responsibility for maternity care, women’s bodies came to be seen in terms of ‘good’ or ‘faulty’, in terms of bearing and birthing babies.
At some time in the early 1900s, for reasons not well documented, women began to have routine pelvic exams during pregnancy. This has been standard routine practice in many countries for over 100 years.
There is, in fact, very little evidence to show the benefits of vaginal exams. A study from 2010 showed vaginal exams during the first eight weeks of pregnancy had no positive benefit.
Another study looked at first trimester vaginal exams, performed when women presented at emergency departments with bleeding or other symptoms. In over 94% of the cases, the vaginal exams had no benefit.
If these pregnancy exams have no benefit, then why do them?
Why Are Vaginal Exams Performed?
Care providers who perform routine vaginal exams during pregnancy claim they’re necessary to check for potential risks for the pregnant woman and her developing baby.
In other words they are done to make sure there’s nothing ‘wrong’ with a woman’s body which might adversely affect her pregnancy and birth.
Sounds reasonable, right?
In the event of a woman having a medical condition, a history of infertility, or surgery that could affect her pregnancy and the health of her baby, then yes, a vaginal examination would be reasonable.
Vaginal exams in the last trimester don’t predict when labour will begin. A baby’s position can be determined just as easily by palpation, and care providers shouldn’t need to check what the cervix is doing unless they believe labour is beginning earlier than is safe for the baby.
If there were medical reasons arising which meant a woman’s baby needed to be born earlier, a vaginal exam could be a reasonable suggestion, as a way to determine the best method of induction.
Many women, however, have vaginal examinations for none of these reasons; they are done simply because they are ‘routine’.
There are risks associated with routine pelvic exams during pregnancy, which you can read about in Pelvic Exam During Pregnancy – Is It Really Necessary?.
What About Saying No To Vaginal Exams?
As a birth educator and doula, I’ve frequently talked about vaginal exams and how to weigh up the risks and benefits of having them performed, either during pregnancy or labour.
Many women find their care providers will recommend doing one pelvic exam early in pregnancy and at least one around 37 weeks gestation. Many care providers, particularly private obstetricians, do weekly exams from 36 weeks onward.
When I talk about a woman’s right to have all the information necessary before she consents to having an exam, I hear such things as:
“My doctor told me I had to have the exam or I was risking my baby’s safety”.
“I agreed to have my cervix checked and my midwife tried to stretch my membranes without asking me”.
“I hate having pelvic exams and found mine to be really painful and embarrassing”.
“I didn’t want to have the exam but my doctor said it was really important she knew if my pelvis was big enough to fit my baby through. When he was born, he was tiny (6lbs)”.
I’ve frequently heard of women being told they were going to have a vaginal exam during labour:
“Just hop onto the bed, and I’ll check how dilated you are”.
“I have to check your cervix on admission to make sure you’re actually in labour”.
Their consent isn’t even asked. Women aren’t given the right to decide whether or not they want a vaginal exam, during pregnancy or birth. Their right to decide whether to proceed with a vaginal exam is being ignored.
A common concern of many women is they don’t know how to tell their care providers they don’t want a vaginal exam. Most of us have been bullied, at some point, by an authority figure; it requires a certain amount of confidence to question what a care provider is recommending.
Women often worry they will be seen as ‘difficult’. They feel threatened with losing a valued part of their birth care or experience if they don’t agree to routine exams. They might feel they have no right to refuse a vaginal exam, or to complain if they are given one without their consent.
Do I Have The Right To Refuse?
Every woman has the right to decide what happens to her body during pregnancy and birth.
However, when women decide not to have a vaginal exam, they come up against difficult situations. Perhaps their midwife is unable to care for them, or they might have to choose to give birth unassisted. They might even agree, finally, to ensure they continue to have the care they want.
And, as seen in the case reported above, regulations in some countries might appear to overrule a woman’s right to choose.
In the US, federal acts, regulations and professional guidelines all clearly state every pregnant woman has the right to choose her maternity care, based on current, evidence-based information.
The American College of Obstetricians and Gynecologists (ACOG) makes the following recommendations with regard to women who refuse medical treatment while pregnant:
- Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.
- The use of coercion is not only ethically impermissible but also medically inadvisable because of the realities of prognostic uncertainty and the limitations of medical knowledge. As such, it is never acceptable for obstetrician–gynaecologists to attempt to influence patients toward a clinical decision using coercion. Obstetrician–gynaecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.
Since all the evidence available shows routine vaginal exams have very few benefits, a care provider needs to have a very strong case to put forward in favour of performing one.
Vaginal examinations should only ever be offered when the information they provide can help women make a decision about medical treatment.
When a woman questions the necessity of a routine vaginal exam, she is asserting her right as a maternity patient to make an informed decision, and asking for the best care from her provider, both of which she is completely entitled to do.